Catherine G Velopulos1, Hasan M Shihab, Lawrence Lottenberg, Marcie Feinman, Ali Raja, Jeffrey Salomone, Elliott R Haut. 1. From the Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado (C.G.V.); Combined Family Medicine and Preventive Medicine Residency Program, MedStar Franklin Square Medical Center, and Johns Hopkins University School of Public Health, Baltimore, Maryland (H.M.S.); Department of Surgery, St. Mary's Medical Center, West Palm Beach, Florida (L.L.); Department of Surgery, Sinai Surgery and ICU Associates, Baltimore, Maryland (M.F.); Department of Emergency Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts (A.R.); Department of Surgery, Banner Desert Medical Center, Mesa, Arizona (J.S.); Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland (E.R.H.); Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland (E.R.H.), Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland (E.R.H.); The Armstrong Institute for Patient Safety, Johns Hopkins Medicine, Baltimore, Maryland (E.R.H.); and Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (E.R.H.).
Abstract
BACKGROUND: Spine immobilization in trauma has remained an integral part of most emergency medical services protocols despite a lack of evidence for efficacy and concern for associated complications, especially in penetrating trauma patients. We reviewed the published evidence on the topic of prehospital spine immobilization or spinal motion restriction in adult patients with penetrating trauma to structure a practice management guideline. METHODS: We conducted a Cochrane style systematic review and meta-analysis and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology to construct recommendations. Qualitative and quantitative analyses were used to evaluate the literature on the critical outcomes of mortality, neurologic deficit, and potentially reversible neurologic deficit. RESULTS: A total of 24 studies met inclusion criteria, with qualitative review conducted for all studies. We used five studies for the quantitative review (meta-analysis). No study showed benefit to spine immobilization with regard to mortality and neurologic injury, even for patients with direct neck injury. Increased mortality was associated with spine immobilization, with risk ratio [RR], 2.4 (confidence interval [CI], 1.07-5.41). The rate of neurologic injury or potentially reversible injury was very low, ranging from 0.002 to 0.076 and 0.00034 to 0.055, with no statistically significant difference for neurologic deficit or potentially reversible deficit, RR, 4.16 (CI, 0.56-30.89), and RR, 1.19 (CI, 0.83-1.70), although the point estimates favored no immobilization. CONCLUSION: Spine immobilization in penetrating trauma is associated with increased mortality and has not been shown to have a beneficial effect on mitigating neurologic deficits, even potentially reversible neurologic deficits. We recommend that spine immobilization not be used routinely for adult patients with penetrating trauma. LEVEL OF EVIDENCE: Systematic review with meta-analysis study, level III.
BACKGROUND: Spine immobilization in trauma has remained an integral part of most emergency medical services protocols despite a lack of evidence for efficacy and concern for associated complications, especially in penetrating traumapatients. We reviewed the published evidence on the topic of prehospital spine immobilization or spinal motion restriction in adult patients with penetrating trauma to structure a practice management guideline. METHODS: We conducted a Cochrane style systematic review and meta-analysis and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology to construct recommendations. Qualitative and quantitative analyses were used to evaluate the literature on the critical outcomes of mortality, neurologic deficit, and potentially reversible neurologic deficit. RESULTS: A total of 24 studies met inclusion criteria, with qualitative review conducted for all studies. We used five studies for the quantitative review (meta-analysis). No study showed benefit to spine immobilization with regard to mortality and neurologic injury, even for patients with direct neck injury. Increased mortality was associated with spine immobilization, with risk ratio [RR], 2.4 (confidence interval [CI], 1.07-5.41). The rate of neurologic injury or potentially reversible injury was very low, ranging from 0.002 to 0.076 and 0.00034 to 0.055, with no statistically significant difference for neurologic deficit or potentially reversible deficit, RR, 4.16 (CI, 0.56-30.89), and RR, 1.19 (CI, 0.83-1.70), although the point estimates favored no immobilization. CONCLUSION: Spine immobilization in penetrating trauma is associated with increased mortality and has not been shown to have a beneficial effect on mitigating neurologic deficits, even potentially reversible neurologic deficits. We recommend that spine immobilization not be used routinely for adult patients with penetrating trauma. LEVEL OF EVIDENCE: Systematic review with meta-analysis study, level III.
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